Child's Last Name
Child's First Name
Child's Middle Name
Gender MaleFemale
Date of Birth
Social Security Number
Street Address
City
State
Zip Code
Preferred Pharmacy Name
Cross Street/ Address
Pediatrician / PCP
PCP Phone #
School District
School Name
Race/Ethnicity (Select appropriate group): AsianBlack/African AmericanLatino/HispanicNative AmericanWhite CaucasianOther
Medication Allergies
Medical History
Child Lives With Mother & FatherMotherFatherGurdian/Other
Parent/Guardian’s Last Name
Parent/Guardian’s First Name
Middle Initial
Primary Phone Number
Alternate Phone Number
Email Address
Opt out of email contact
Name
Phone Number
Relationship
Children’s Health Pediatric Group may disclose Medical and Billing information to this contact YesNo
Child’s Name:
DOB:
HIPAA/FERPA: All students have health issues that must be handled in a confidential manner. Peds Purpose, LLC will share confidential information only in the following situations: • When the student’s education is affected • When addressing a student’s healthcare needs • When safety is an issue • And other situations specified by law For example, Peds Purpose, LLC may discuss the student’s medication and other health care needs with the appropriate staff members who will administer the student’s medication and provide care to the student while the student is at school.
I, the undersigned, • give permission and consent for my child to have treatment through and by Peds Purpose, LLC. I understand the nature of this treatment, the way it is provided, and the details and limitations of Telemedicine. • give permission for Peds Purpose, LLC to receive information from the school about my child’s healthcare history. • agree to release all records related to this treatment to the Primary Care Provider • agree that I will be responsible for all costs associated with said treatment and that I will provide any insurance information as requested. All costs and fees not covered by insurance will be my responsibility. • agree that the Camden City Board of Education, nor their staff, will be held liable for the services provided by Peds Purpose, LLC • As Parent/Guardian of the above student, I: • authorize the release of any information necessary to process insurance claims for payment of benefits Peds Purpose, LLC. • authorize payment of benefits to Peds Purpose, LLC for services rendered. • have provided details of all insurance policies that cover my child. The information above and on the preceding page is true and complete to the best of my knowledge.
Parent/Guardian name PRINTED:
Parent/Guardian SIGNATURE:
Date:
No Telemedicine Services can be provided without a signed consent form.
Please select the type of insurance for the patient Commercial InsuranceCHIPMedicaidNone
Name of Person Responsible for Paying the Bill
Relationship to Child FatherMotherOther
Address Same as Child? YesNo
Street Address: Other (City, State, Zip Code)
Policy Holder Relation to Child Child/PatientMotherFatherGuardian/Other
Name of Insurance Policy Holder
Employer
Insurance Name
Insurance Phone Number
Insurance ID#
Group#
